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Sex Determines Cardiovascular Hemodynamics in Hypertension

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Sex Determines Cardiovascular Hemodynamics in Hypertension Journal of Human Hypertension (2015) 29, 610–617 © 2015 Macmillan Publishers Limited All rights reserved 0950-9240/15 www.nature.com/jhh ORIGINAL ARTICLE Sex determines cardiovascular hemodynamics in hypertension P Krzesiński, A Stańczyk, G Gielerak, B Uziębło-Życzkowska, M Kurpaska, K Piotrowicz and A Skrobowski The aim of this study was to evaluate the influence of sex on cardiovascular hemodynamics and heart remodeling in 144 patients with arterial hypertension that underwent: (1) echocardiography (that is, indices of left ventricular diastolic function: e′, E/e′), (2) impedance cardiography (that is, systemic vascular resistance (SVR), total artery compliance (TAC) and Heather index (HI)) and (3) applanation tonometry (augmentation index (AI), central systolic and diastolic blood pressure (CSBP, CDBP), central pulse pressure (CPP)). Women, in comparison with men, revealed to have: (1) stiffer arteries—lower TAC (1.93 ± 0.55 vs 2.16 ± 0.59 ml per mm Hg; P = 0.025), higher CSBP (128.7 ± 14.9 vs 123.4 ± 13.2 mm Hg; P = 0.036), CPP (39.9 ± 9.5 vs 33.8 ± 9.0 mm Hg; P = 0.0002), AI (31.5 ± 8.7 vs 17.5 ± 12.7%; Po0.00001), SVR (1257.6 ± 305.6 vs 1091.2 ± 240.7 dyn × s × cm−5; P = 0.002) and (2) higher left ventricular performance—HI (16.3 ± 4.3 vs 11.7 ± 3.2 Ohm × s2; Po0.00001). In women CSBP, CPP and AI were more clearly associated with left ventricular filling pressure (e′)(r = − 0.39, r = − 0.45, r = − 0.44, Po0.01; respectively). These relations were remarkably weaker in men. Hypertensive women characterized with lower large artery compliance, more pronounced augmentation of central blood pressure and more distinctive association of central blood pressure with left ventricular diastolic function. Sex differences in cardiovascular function can impact the individualized management of arterial hypertension. Journal of Human Hypertension (2015) 29, 610–617; doi:10.1038/jhh.2014.134; published online 29 January 2015 INTRODUCTION differences in the mechanisms of cardiovascular dysfunction and Arterial hypertension (AH) is the main modifiable risk factor of remodeling in hypertensive males and females that can be cardiovascular diseases. Young adult women have lower blood depicted by these methods. pressure (BP) than men, whereas, after the fifth decade of life, the prevalence of AH in females increases rapidly. It results in the PATIENTS AND METHODS acceleration of cardiovascular remodeling and steeper increase of cardiovascular risk.1–4 It can be explained by the change of female Study population This study included patients with at least 3-month history of AH defined hormonal status and the loss of cardiovascular protection 1 provided by estrogens in premenopausal women.4–6 In addition, according to the European Society of Cardiology guidelines. Exclusion criteria comprised: (1) confirmed secondary AH, (2) AH treated with three hypertensive females, even in the absence of large coronary or more medicines before recruitment, (3) heart failure, (4) cardiomyo- artery disease and left ventricular systolic dysfunction, tend to pathy, (5) significant heart rhythm disorders, (6) significant valvular disease, experience more symptoms related to AH, including impaired (7) kidney failure (GFR below 60 ml min− 1 per 1.73 m2), (8) chronic exercise tolerance and chest pain.6 Although women with AH are obstructive pulmonary disease, (9) diabetes, (10) polyneuropathy, more aware of the need of treatment and visit physicians more (11) peripheral vascular disease, (12) ageo18 years and 465 years. The frequently2 they do not reach satisfactory control of BP.3 The subjects treated with hypotensive drugs were recommended to discon- question whether, and how, the antihypertensive therapy should tinue taking them 7 days before the examination. The group selected to the analysis comprised patients from clinical be sex-adjusted remains without satisfactory answer. study, registered at ClinicalTrials.gov—NCT01996085. The study was Several studies reported sex differences in cardiovascular conducted according to Good Clinical Practice guidelines and the function in patients with AH. They revealed that premenopausal Declaration of Helsinki, with the approval of local ethics committee (no women were characterized with relatively higher vascular 21/WIM/2011). Each patient provided written informed consent to stiffness, better left ventricular performance and different patterns participate in the study. of modulation by the autonomic nervous system.5,7,8 However, the The clinical examination was performed in the morning hours with knowledge about the mechanisms underlying the different consideration of cardiovascular risk factors and symptoms indicating secondary cause of AH.1 The office blood pressure measurement was patterns of ‘hypertensive disease’ in males and females is still fi performed automatically (Omron M4 Plus, Japan) by a technique compliant de cient. Especially the sex-related differences in relations with the European Society of Cardiology guidelines.1 The average value of between those parameters are poorly known. Thus, the need for the two measurements was used as the final reading. studies providing comprehensive picture of complex nature of interaction between heart and vessels still exists. Echocardiography The aim of our study was to evaluate the influence of sex on Two-dimensional echocardiography was performed using standard para- cardiovascular hemodynamics, heart structure and function. We sternal, apical and subcostal views (2.5 MHz transducer; VIVID S6 GE used three noninvasive techniques to provide combined hemo- Medical System, Wauwatosa, WI, USA). The dimension of the left atrium, dynamic assessment—echocardiography, applanation tonometry left ventricular end diastolic diameter and interventricular septum and impedance cardiography. We hypothesize that there are diameter were measured in the parasternal long-axis view in late diastole Department of Cardiology and Internal Diseases, Military Institute of Medicine, Warsaw, Poland. Correspondence: Dr P Krzesiński, Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141 Warsaw 44, Poland. E-mail: [email protected] Received 15 October 2014; accepted 11 December 2014; published online 29 January 2015 Sex and hemodynamics in hypertension P Krzesiński et al 611 of left atrium and left ventricle (LV), respectively. Left atrium area was Applanation tonometry calculated from apical four-chamber view. Left ventricular ejection fraction Assessment of central blood pressure (CBP) and augmentation index (AI) was calculated according to the Simpson’s formula using a two- was performed noninvasively using the SphygmoCor system (AtCor dimensional image of the LV chamber during systole and diastole in the Medical Inc Pty Ltd, Sydney, NSW, Australia). Radial artery pressure four- and two-chamber apical views. waveforms were recorded at the left wrist, using applanation tonometry The left ventricular hypertrophy (LVH) was diagnosed according to the with a high-fidelity micromanometer (Millar Instruments, Houston, ASE-recommended formula for the estimation of left ventricular mass TX, USA). The arterial pulse waves were processed by the SphygmoCor index (LVMI) from two-dimensional linear LV measurements and indexed software (version 9.0; AtCor Medical Inc Pty Ltd) and the corresponding 4 − 2 to body surface area (BSA, cutoff values for men LVMI 115 g m , for aortic pressure waveform was generated from the radial artery waveform 4 − 2 women 95 g m ). using a validated transfer function with identification of inflection fl Mitral valve in ow was recorded in the apical four-chamber view with point resulting from the wave reflection and the incisura resulting from pulsed wave Doppler gate positioned in the LV on the level of the mitral the aortic valve closure.11 Augmentation pressure (AP (mm Hg)) was valve edges. The following parameters were measured: E/A ratio and phase calculated by the maximum systolic pressure minus pressure at the fi E deceleration time (EdecT). The apical ve-chamber view enabled inflection point. Only high-quality recordings (quality index of 480%) fl simultaneous registration of the ow pattern through aortic and mitral were included in the analysis. The measurements were performed in the valves and isovolumic diastolic time calculation. Tissue Doppler imaging supine position just after examination by ICG. The radial pulse and was performed in the apical views to acquire mitral annular velocity. The transferred aortic blood pulse were calibrated against the last measure- sample volume was positioned at 1 cm within the septal insertion sites of ment of brachial systolic BP (SBP) and diastolic BP (DBP) by oscillometric the mitral leaflets and adjusted as necessary (usually 5–10 mm) to cover module of the Niccomo device. The following parameters were included the longitudinal excursion of the mitral annulus in diastole. In addition, in the analysis: central systolic blood pressure (CSBP (mm Hg)), mitral septal annulus early diastolic velocity (e′) was measured and E/e′ central diastolic blood pressure (CDBP (mm Hg)), central pulse pressure ratio was calculated. The diagnosis of left ventricular diastolic dysfunction (CPP (mm Hg)) and AI. was based on the current guidelines.9,10 Following values were considered abnormal: e′o8cms− 1; left atrium 440 mm for men and 438 mm for women; E/Ao0.8, EdecT4200 ms, isovolumic relaxation time ⩾ 100 ms, Statistical analysis E/e′ ratio 48. The statistical analysis was performed using Statistica 7.0 (StatSoft,
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